Surviving the Roller Coaster Emotions of Infertility Treatment

The experience of infertility is a rollercoaster of hope and disappointment. Treatment presents an opportunity for hope as well as a new set of challenges. It is common to feel overwhelmed and alone. In this webinar, we hope to describe the typical range of emotions and reactions for individuals and couples along with a practical discussion of coping strategies.

Sarah Ramaiah: Surviving the Roller Coaster Emotions of Infertility Treatment. I am Sarah Ramaiah, Curriculum Designer at ASRM. This webinar is presented by the American Society for Reproductive Medicine in collaboration with the Mental Health Professional Group.

Today's moderator is Dr. Piavi Lake. Dr. Lake has been in private practice as a general adult psychiatrist in Charleston, South Carolina since 2002. She works individually with adults 18 years to geriatric ages. She utilizes psychopharmacology and psychotherapy to treat a variety of problems, most commonly depression and anxiety. She has a special interest in treating those with infertility issues, women with perinatal and postpartum mood problems, and mood problems related to hormones. She also performs third-party evaluation screenings and psycho-educational meetings for gamete donors, gestational carriers, and donor gamete recipient's intended parents. She has served on a number of committees of the Mental Health Professional Group including as Past Chair of the Executive Committee. She is currently in her second year as a member of the Patient Education Committee of ASRM.

Before we begin, please note this webinar was developed by the American Society for Reproductive Medicine as an educational resource and service to its members, practicing clinicians, and patients. While this webinar reflects the views of the panelists, it is not intended to be the only approved standard of practice or to dictate an exclusive course of treatment. Attendees should always use their best judgment in determining a course of action and be guided by the needs of the individual patient, available resources, and institutional or clinical practice limitations. Please note all attendees will be muted except the presenters. Time at the end of the presentation will be reserved for questions. Please type a question in the question window at any time. We will read as many selected questions as possible to the presenters during the allotted question-and-answer time. A recording of this webinar will be archived on the ASRM website in the coming weeks. Please watch your email for a notification. I will now turn the presentation over to Dr. Lake to introduce today's speakers.

Piavi Lake: Hello. Good afternoon and welcome to our webinar. The topic is surviving the roller coaster emotions of infertility treatment. The experience of infertility is a roller coaster of hope and disappointment. Treatment presents an opportunity for hope as well as a new set of challenges. It is common to feel overwhelmed and alone. In this webinar we hope to describe the typical range of emotions and reactions for individuals and couples, along with a practical discussion of coping strategies. As mental health professionals working in this field for many years, we have heard a lot about people's experiences with infertility treatment and are frequently asked about how to cope. We also know that people ask their reproductive endocrinologists and their nurses and they seek other resources online or through books or support groups. So we thought that this would be a good topic to address and hopefully give you some ideas about the typical reactions of infertility and how to cope. Thank you.

Our first panelist is Dr. Julia Woodward, PhD. Dr. Woodward is an Associate Professor in the Departments of Psychiatry and Behavioral Sciences and Obstetrics and Gynecology in the Duke University Health System. She has directed the Patient Support Program at the Duke Fertility Center for over 15 years. Clinically, she specializes in working with patients facing infertility, pregnancy loss, third-party reproduction, fertility preservation, and perinatal mood disorders. She trains clinical psychology post-doctoral fellows, interns, and PhD students, serves on the Executive Council for the Society for Assisted Reproductive Technology and has chaired several committees for ASRM's Mental Health Professional Group. She has published numerous peer-reviewed journal articles and book chapters on the psychosocial aspects of reproductive medicine and later-life parenting and lectures internationally on these topics. Dr. Woodward will be speaking on Hope and Heartbreak: Common Emotional Responses to Fertility Treatment. Thank you Dr. Woodward.

Hope and Heartbreak: Common Emotional Responses to Fertility Treatment by Dr. Julia T. Woodward, PhD

Julia Woodward: Thank you so much for inviting me. I really appreciate this opportunity. So I'm really going to be honing in today on the sort of common emotional responses that our patients are facing when they're going through the fertility journey. And I have nothing to disclose. So we'll talk about the responses that patients go through both when they are faced with a fertility diagnosis and when they're going through fertility treatment, which is a unique stressor in and of itself. And I also wanted to highlight a couple of the factors that really intensify the emotional distress that our patients are facing, specifically the pervasiveness of the fertility struggle and the number of life domains that become impacted. And also this sort of monthly emotional roller coaster that patients experience.

I wanted to start by highlighting some research that was done by another panelist Dr. Domar. She and her colleagues in 2010 did an online survey of several hundred women between the ages of 18 and 44 who were struggling with fertility problems. And what they heard from this group was that there really were a number of very specific kinds of struggles that they experienced. So 74 of the women said that they felt resentful about those who took getting pregnant for granted. Two-thirds of the women said that they were tired of suggestions about how to get pregnant. It wasn't a problem of knowing what to do, it was a medical situation that just wasn't happening. 58 of the women felt like they had waited too long to start their family-building journey. 65% of the women said they felt really uncomfortable around pregnant women and moms of young babies. Over half of the respondents felt something much more global. So they reported a feeling of inadequacy as a woman. And about a quarter of the respondents said that infertility treatment or struggling with the fertility problem had made sex a more anxious time for them. I actually think that might be sort of an underestimation of how difficult that problem is and how pervasive that issue is. Finally about 41 of these patients reported that the fertility struggle had made it more difficult to talk to others and be as open. But it wasn't all negative impacts that were identified. About a third of the participants said that having people to talk to had made the experience easier. And another third felt like the experience was bringing them closer to their partner, that they were really able to support each other through a very difficult experience, and that was sort of a powerful reassuring factor.

I wanted to also highlight some of the themes that I hear so commonly in my clinical practice. In working with patients who are going through the fertility journey, patients will talk about feeling like a failure as a person and as a woman. As we saw on some of that earlier data they will talk about the way in which this experience feels like it's taking over their life, like it's pervading so many of the aspects of their life. They'll feel like they waited too long, asking themselves questions about why they didn't start the family-building process sooner in life. They'll ask questions of themselves like why me? Is there something wrong with me? Is this my fault? Am I to blame? And they describe a profound sense of isolation, really feeling alone, and that everybody else is having this experience so much more easily. Our patients are often experiencing a sense of helplessness, feeling like they have no control over this outcome. And many times, fertility patients, they're go-getters, they're problem solvers; they know how to tackle something and move their way through it through hard work. But those sorts of most commonly used coping strategies don't apply well in the world of fertility or pregnancy loss, and so they feel like they don't have any other tools to use to deal with this.

Patients are commonly going through a fertility journey with a partner. And so they're having to kind of get in alignment with a partner or discover that they are not in alignment and sort of feeling like, you know, they're at an impasse about what to do next if treatment isn't working.

And lastly this idea that they are fatigued. They can't take much more of it because it's not only financially very expensive, but it's an exhausting process, and it goes on and on. And so just kind of representing graphically the way in which fertility problems pervade so many life domains for our patients, one of the most difficult aspects that patients talk about is sort of the social piece, that they both are the recipient of well-meaning questions about their fertility status or you know 'when are you gonna start trying to have a child'. But folks don't realize that this is something that they're struggling with often privately.

They also feel a great divide between themselves and their friends who are already pregnant or parenting young children. And frequently being bombarded when they're just going through their social media feed with images around pregnancy and fertility. Patients often also describe the way in which the fertility problem is impacting them at work because they have to take lots of time off to come into the center of the clinic for appointments, scans, and consultations. And so they're having to miss work and either decide to explain or not explain to bosses and co-workers about their absences. As we've touched on, and you'll hear a lot from Dr. Kaplan in a moment, again, this is a dyadic problem for many people. This is an issue that you face with a partner, and so patients often find that there's a discrepancy between their wants and needs and their partner's wants and needs. And there's often this impact on a couple's sexual functioning where sex has gone from being about connection and passion to being something that's very timed. It just feels much more artificial to them. And so they'll talk about sex used to be about recreation, and now it's about procreation, and it's fundamentally changed how we feel about it.

Patients are facing very expensive fertility treatments and they're often struggling with poor insurance coverage. And so there's a lot of conversation around how much is going to be covered by my insurance, how will we be able to afford these out-of-pocket expenses, and how does paying for fertility treatment impact the other financial goals that we have, the other things that we thought we were going to save for or spend money on.

As you might imagine, experiencing impacts in all of these multiple domains really then begins to take a toll on mood. So I just want to spend a moment looking at this kind of emotional rollercoaster idea. Sort of the idea that sparked the title of the webinar. If along the x-axis, we're looking at time in a particular treatment cycle, weeks one through four. And along the y-axis looking at mood. From low to high, patients will often describe that in the first couple of weeks of the cycle, when they are in the treatment phase, it's a time of action, and so there's a real sense of sort of engagement and excitement and hope. And so their mood is kind of rising. And then after the fertility procedure occurs, after they have the insemination or the transfer perhaps, then they go into the waiting phase. The two-week wait. And they start to experience a real drop in mood. Much more anxiety begins to show up. Worry about the outcome and if the cycle is not successful. Then there's a great sense of disappointment, frustration, maybe even devastation. And then they're right back at week one of the next cycle and sort of need to ride the roller coaster all over again. And so, as a result, sort of all of the life domains impacted. And this kind of monthly cyclical emotional rollercoaster, what we see is that it's very common for patients to be struggling with their mood, particularly depression and anxiety.

And so this was a really nice study done by our colleague Lauri Pasch at the University of California San Francisco. And she and her colleagues queried 626 men and women who were at the start of fertility treatment. And they were really given these measures and assessments kind of before they had done their first treatment cycle. What Dr. Pasch found was that 57 of the women reported experiencing depressive symptoms, not just being blue, not just feeling down, but being in the clinical range of experiencing depressive symptoms. And so did a third of their male partners. And the situation with anxiety was even more profound. So, 75 of the patients reported experiencing clinically significant anxiety, and 61 of the male partners did as well.

So those numbers, I think, really just capture how common and how intense negative mood can be for fertility patients. And of interest and also sort of, I think, pretty difficult was the fact that only about one in five of the women who were struggling with their mood were receiving any form of psychological care or treatment. So, patients who were struggling the most really were doing so on their own and had this very strong sense of being alone.

And so I just want to highlight for patients that, in fact, you're not alone. It is common and normal to experience emotional struggles while going through fertility challenges and undergoing fertility treatment. And that those of us who are working in these centers with patients on the fertility journey really understand that. And we expect these kinds of emotional reactions. And that's certainly true of the mental health providers who have the opportunity to serve these patients. But it's just as true for the nurses and the doctors and the lab staff and the front desk people. We are very aware of just how intensely stressful this experience is. There are targeted coping strategies that folks can learn to cope better and feel better while they're going through this journey. Stay tuned for more of those strategies in this webinar today.

Also, there is a group of about 600 people around the United States that really specialize in these emotional aspects of fertility treatment. And you can find them if you do a Google search for the Mental Health Professional Group on ASRM. There's a really easily accessible metric for identifying people who might be local to your area. So professionals are available for support and I really encourage folks to reach out. So thanks very much. I appreciate the opportunity to participate with this great group.

Lake: Thank you, Dr. Woodward. That was really informative and helpful to know.

So next we have Dr. Danielle Kaplan. Dr. Kaplan is a
psychologist in private practice in Manhattan and a clinical assistant professor in the Department of Psychiatry at the NYU School of
Medicine. Her areas of specialization include reproductive and perimeter perinatal mental health and cognitive behavioral therapy. She is
dedicated to helping women whose journey through family-building is more complicated than they had anticipated. Dr. Kaplan is an active
member of the American Society for Reproductive Medicine's Mental Health Professional Group and is the Immediate Past Chair of its Certificate
Course Committee. Dr. Kaplan currently serves as a mentor for emerging professionals in the field and is a member of the Mental Health
Professional Group's Anti-racism, Equity and Inclusion Task Force. She is also co-author of the book Supervision Essentials for Cognitive
Behavioral Therapy. Dr. Kaplan will be speaking with us today about Hanging in Through Infertility: A Toolkit For Couples. Welcome, Dr. Kaplan.

Hanging "In" through Infertility: A Toolkit for Couples by Danielle A. Kaplan, PhD

Kaplan: Thank you so much. I'm so glad to be here today. And for those of you who we can't see, we're so glad that you're here with us as well. So we look forward to your questions and your comments at the end of the presentation.

Let me begin by saying that I have nothing to disclose except that I myself am an infertility survivor which means that my partner is also an infertility survivor. In the course of our time today I'm hoping we can do a few things together.

The first is to identify the tasks that a couple facing infertility has to navigate. And to understand that because you are different people, you might cope with those tasks very, very differently, and that might have an impact on your relationship as you're going through a fertility journey. And then, hopefully, we can learn some techniques together for maintaining communication and connection as you go through this process of infertility.

If you're part of a couple, infertility is a couple's problem. The estimate that we tend to use is that one in eight couples will experience infertility. Some people think this estimate is low in the black community. This estimate is very low. We believe that black couples probably experience infertility at about twice the rate of white couples. If anybody's interested, the prevalence of being left-handed which I also happen to be, is one in ten. So it is way more common to experience infertility than it is to be left-handed or to have red hair for example. About a third of infertility problems are what we call the female factor, about a third are what we call the male-factor, and about a third are attributable to both members of a couple, or they're simply unexplained.

But what we need to understand is that although people don't tend to talk about this very openly, all kinds of couples will experience infertility. Couples of all races, ethnicities, religions, socioeconomic statuses, genders, and sexual orientations this is a very common problem, and it's a problem that we were never taught how to cope with together. If you're navigating infertility you have four main jobs. The first is to regulate your own emotions, and as Dr. Woodward spoke to you, that's a very tall order in and of itself. But then you have a partner, and you need to be aware of his or her emotional needs while they're going through the very same process. And then the two of you together form a relationship, and taking care of that relationship is a task in itself. And while all of this is happening you have decisions to make, you have logistics to address. It's a very, very tall order to get through infertility together, so it's not at all surprising that different people have different coping styles. I've listed some of them here, and I'm not going to go through the whole list, but what I think is important to understand is that some of these coping techniques involve facing infertility head-on, either logistically or emotionally. And other techniques involve trying to take a little more distance. look on the bright side, or distract yourself, or involve yourself in other activities. So it's no surprise that these coping styles can conflict. None of them are wrong but they can be in conflict with each other. And when each member of a couple has a different coping style, which is not at all unusual, it can cause stress in the relationship.

Before we go any further I want to say very clearly, please don't panic. As Dr. Woodward pointed out, about a third of couples report that their journey through infertility brought them closer together as a couple. And here's the really important part of that statement - they say that this is true whether or not they had a baby at the end of their fertility journey. So infertility can be a crisis in the life of a couple. It can also be a real growing opportunity in the life of a couple.

And what I'm going to talk about for the rest of the time that I have today is how to try to make it more the latter than the former. First things first, please keep the lines of communication open with your partner. You probably didn't plan for this. Some people go into a relationship knowing that they're going to have difficulty conceiving but most people don't. So what you probably talked about is where you want to live, whether you like sushi, or what you want to name your children. You probably didn't talk about how many cycles of IUI you'd be willing to do or whether you would prefer adoption, donor conception, or child-free living. It's just not something many of us are taught to talk about. So please understand that this is new territory for you both.

The second thing that I will remind you of, and I remind couples of this in my office all the time, is you aren't married to yourself. So the idea that you will be in lockstep down the line about how to deal with infertility is highly unlikely because you probably weren't lockstep down the line about most things before this. So it turns out that it's not whether you agree that impacts adjustment to infertility, and it's not even whether you cope the same way, it's the quality of your communication and it's your ability to understand your partner's style and your partner's needs that impact how you're going to come out the other end of the journey together.

Here are a few ways to improve communication with your partner during this infertility journey. I actually stole the title of this slide from the person I co-wrote the book with, so thank you, Dr. Newman. Find the logic in your partner's illogic. Your partner's coping style might not be the same as yours but it serves a function for them. So try to understand why they're coping the way they are. And maybe a taller order but a very important one, recognize the ways in which your partner is attempting to support you as you go through this journey together. So, for example, there might be two members of a couple where one of them wants to watch a movie and joke around and have a date night, and the other one might need to remind herself that she's trying to keep things light to give us both a break from the heaviness of this journey. The other person might want to read the research, look at a website, or make a list of questions for their doctor. And then it falls to her partner to remind herself that she wants to talk about the next steps so we can find a way to grow the family that we both so badly want. If you've gotten this far in your journey, you're probably used to being good support for each other, so it might be a little jarring if you're not the optimal support for each other now. But in this fertility journey, it's really important, and it's really helpful to make room for yourself and your partner to have other sources of support. So one person might say I am going to trust the people I know and love. I'm going to talk to my friends. I'm going to talk to my mother. I'm going to go to a peer-led support group of other people who are experiencing what I'm experiencing. And the other person may say no way I'm strictly data here. I'm going to the internet. I'm going to therapy. I'm talking to my doctor, but boy, am I not talking to my family about this. The more room you can make for each of you to access the kind of coping that serves you best, the more that you're really fulfilling task number two here, which is making room for your partner's emotions while getting your own emotional needs met.

I would also remind you, and this is hard to remember, that infertility may take up a lot of your time. It may take up a lot of your money. It may take up a lot of your head. But your relationship is more than infertility. So if you have a lot of decisions to make, set aside specific times to talk about them. And then set aside a lot of time not to talk about them.

Ask for the kind of support that you need. As much as your partner loves you, as much as your partner wants you to have what you want and need, they cannot read your mind. So if you haven't been good at asking, this is the time to get good at it. Try to spend non-fertility-related time together. And make room for lots of different kinds of intimacy. As Dr. Woodward referenced in, I also believe we could probably have a whole webinar just on sex and infertility. But for now, I'm just going to remind you that closeness isn't always sex. Sex isn't always intercourse and intimacy means a lot of things besides what happens in the bedroom. So please make room for all of it, okay?

But here's the $64,000 question - what if you just don't agree on what to do right? Remember that slide that said don't panic? Don't panic again because you have disagreed before. You've disagreed on many things. So the idea that you start in a place of disagreement doesn't necessarily tell you where you're going to wind up. Oftentimes, we disagree on a behavior, but we can support our partner in the wish that motivates that behavior. So for example, a person who says I am willing to go this far and no farther and stop, might have the underlying wish of preserving their bank account. So that you can go on vacations together buy your dream house and go on adventures. A person who says I want to go all the way to the end of the line might be saying I want to feel like I have tried everything that I can so that I can look back on this period and feel good about the choices I made. Before you decide whether your partner's proposed course of action makes sense or doesn't make sense, make room for understanding the wish behind it. And then look for places where you agree. We both, for example, want to educate ourselves or we both want friends and family to remain important in our lives, even though for one person that might mean I never go to a baby shower and for the other person it means I want to be at every family event.

Every option, even the one that you want, has pros and cons. So you might want to sit down and actually make a list of the pros and cons of every option that you're considering. And if it's hard to do that, switch sides and see if you can see and express your partner's point of view on the pros and cons of the option that they prefer.

And finally keep a connection to what you value as individuals and what you value as a couple. When couples are in my office, and they're struggling with infertility, I will always ask them what brought them together in the first place. And it's never their ability to navigate an insurance company. And it's never their ability to remember how to take certain medications. It's because they shared common values or they shared a common hobby or they shared a common desire to make a certain kind of difference in the world. So try to keep connected to those things as you go through the maze of decision-making, okay?

But what if you still don't agree? Dr. Woodward mentioned there are mental health professionals in almost every state in the country and in many countries around the world who specialize in working with couples in the very position that you're in. So here is ReproductiveFacts.org, ASRM's patient-centered education area on their website. If you go to find a health professional and plug in our information, you will find one of us, and we are here to help. Thank you so much.

Lake: Thank you, Dr. Kaplan. Again, that was really interesting and hopefully very encouraging. I seem to find it encouraging myself, so thank you.

Our next presenter is Dr. Alice Domar PhD. She is the Executive Director of the Domar Center for Mind/Body Health and the Director of Mind/Body Services at Boston IVF. She established the first-ever Mind/Body Center for Women's Health as well as the very first Mind/Body Program for Fertility. As a senior staff psychologist at Beth Israel Deaconess Medical Center and an Associate Professor of Obstetrics/Gynecology and Reproductive Biology at Harvard Medical School, Dr. Domar has earned an international reputation as one of the country's top women's health experts. Her cutting-edge research focuses on the relationship between stress and different women's health conditions, and for creating innovative programs to help women decrease these physical and psychological symptoms. Over the years, she has collaborated with Boston IVF on many ground-breaking studies, including antidepressants for pregnancy, stress and fertility, acupuncture and success rates, eating disorders, and pregnancy, among many more. Dr. Domar will be talking to us today about specific coping strategies as you go through your fertility journey.

Coping Strategies by Alice D. Domar, PhD

Alice Domar: Thank you, Dr. Lake for including me and thanks to ASRM for inviting me to join this seminar. So I do have disclosures. I'm the co-owner as you can see of the FertiCalmPro and FertiStrong apps. I'm a speaker for a number of different organizations but I'm really going to talk about coping because, yes I'm a psychologist, and yes I do a lot of research and a lot of counseling, but my real focus is on interventions, is on researching what are the best strategies and ways that individuals and couples who are experiencing infertility can feel better. Because, as you know, my colleagues talked about, you know that Dr. Pasch's studies out of California, you know a lot of our patients are very anxious and depressed. And I just don't think that's okay. I've been really dedicated my whole career to try to help our women, men, and couples, and individuals to learn strategies that we know are going to help them feel better. And these strategies are either physical, psychological, or behavioral. You know there's no one strategy for everybody. And so I would never sit a patient down and say you need to learn to meditate. Because it's a very individual thing.

And so I'm going to describe a number of these strategies and I think you might want to just sort of pick and choose which ones you think might work best for you. And some, for example, when you're very anxious a physical strategy like relaxation might be best for you. And you know, if you're sort of in the waiting period, maybe they're behavioral interventions that work best for you. But there's there's no one-size-fits-all. You really have to recognize your uniqueness and what you think will help you feel better.

So in terms of physical approaches to stress relief, the two main ones that we teach are relaxation techniques. And the first is called Mini Relaxations. And I've had two patients today tell me that minis just sort of saved their lives while they were doing an IVF cycle. Mini Relaxations are basically based on diaphragmatic breathing, and they work by distracting your mind while at the same time increasing a sense of relaxation. And so the way to do a mini, and you know I don't want to really walk you through it because I suspect some of you might be driving right now, is you either keep your eyes open or closed, and probably better if you're driving to keep them open, and you in effect slow down your breathing and you breathe in what we call a diaphragmatic fashion. So that as you inhale your chest and abdomen rise as you inhale and fall as you exhale. There are a number of different ways to do minis. The easiest one is, again if you're not driving, is to sit quietly. You know, close your eyes, take a couple of nice slow deep breaths, and count down from 10 down to zero One number for each breath. So you start at 10, and then you exhale, you go nine, exhale, etc. These are amazing for blood work and ultrasounds, and before you call the doctor's office for test results, you get stuck at red lights. I mean minis are really extraordinary because you take your lungs everywhere you go. So no matter where you are, no matter what the situation, a mini relaxation is just going to make you feel less stressed and more in control.

We also teach our patients different relaxation exercises. There are thousands of ways to elicit the relaxation response. And there are probably thousands of apps that help guide you through. I think at this point now, I do recommend to my patients that they try to use an app because it's much easier to do any of these relaxation strategies if you have a nice voice actually guiding you through it. The ones that my patients find work best are progressive muscle relaxation, autogenic training, imagery, and yoga. I think if you sort of run on the anxious side, progressive muscle relaxation and autogenic training are really good because they're very focused, and there are two basic advantages to learning relaxation techniques. One is that you feel better in the moment which is really nice if you've had a tough day and you sit down and you meditate for 20 minutes. You're going to feel better. Perhaps more importantly, if you incorporate some form of relaxation into your day-to-day life within a few weeks your baseline is just going to come down. You're going to start sleeping better. You're going to be less irritable. You're going to have fewer headaches. You're just going to feel like a calmer person.

And finally under physical is exercise. You know I literally keep a pair of sneakers in my office, or I did before the pandemic. And if I have a patient who says I can't exercise we'll just go for a walk together so that they can see that exercise is such an incredible stress reducer. There's some really elegant research out of Duke showing that people who are depressed who start exercising become less anxious and less depressed. This is not, I'm not talking about running the marathon. I'm literally talking about walking for half an hour a day. Now, obviously, you know a lot of infertility specialists don't want their patients vigorously exercising. So I'm not talking about vigorous exercise. I'm really talking about walking, yoga, pilates, etc. And probably the easiest way to do this is to get a buddy. One of my patients had gained a lot of weight during her infertility treatment and wanted to start exercising but couldn't quite get motivated. She grabbed her mom, and they're walking together every day. It's been just a really great thing for both of them because my patient is getting the exercise she needs to help her with some weight loss, but she also has social support, and her mom is telling her, okay, it's time to walk every day. So I think you know that's probably the easiest way to start exercise. You have someone to sort of get you going.

You know psychological approaches to stress relief. We are our own worst enemy. Nobody is as mean to you as your own mind. We are cruel to ourselves and we have these thoughts that go through our heads over and over again. And that's almost always negative. It's, you know, I'll never have a baby; the infertility is all my fault; I'm not going to be happy until I have a baby; I must have done something to cause this. And I'm sure my colleagues and I could come up with, you know, an hour's worth of negative self-talk that we've heard our patients say. And you know it's just what we think is the way our minds work. We just tend to the negative. But listening to these thoughts over and over in your head is just not doing you much good.

And so we we help our patients with what we call positive or cognitive restructuring. We ask a series of four questions. So, for example, you know, I'd say most of my patients have this fear going over in their head. You know, I'll never have a baby. So I say, does this thought contribute to your stress? And they'll say yeah of course it does. You know, every time I see a pregnant woman or a new baby, I'm thinking, oh my gosh, I'm just never gonna have a baby. So then I ask where'd you learn this thought? And they think well, I don't know. You know my doctor has never said to me, you'll never have a baby. So I guess it's kind of my fear speaking. Like I'm just terrified that I'm never going to have a baby. So that gives us some sort of good solid information. Then, we move on to what we can do with this thought. Is it logical? And the answer might be, well it feels logical. You know everyone I know has been getting pregnant. We've tried for so long we've done a couple of treatments, but they haven't worked. But is it logical to say I'll never have a baby? No, because I wouldn't be trying. I wouldn't be going to see a doctor. I wouldn't be in any treatment if I knew that nothing would work. So then I ask, is this thought true? Well, you know, until you asked me about it, my patients would say it felt true. But no, I can't say for sure I'll never have a baby. So if I dig really deep, I do have hope, so no, it's not true that I'll never have a baby. And so if a patient starts with I'll never have a baby they've gone through those four questions. She realizes that negative thoughts aren't logical and true.

What is logical and true? So maybe it's I'm doing everything. We still have treatment options to try. You know, maybe this is a good time, like my patient, to improve my health habits. Maybe I want to eat better. Maybe I want to lose weight. And you know, a lot of my patients just really like the mantra - somehow, someway, I'm going to be a mom. So there are lots of behavioral approaches to stress relief. And now I'm running out of time, but I'm from Boston, and we talk really fast here.

So the number one rule that I tell every single patient is you've got to take care of yourself. You've got to self-nurture. But there are other things that you can do. So the first thing you do when you wake up in the morning - think of one nice thing you can do for yourself that day. It could be calling a friend. It could be watching something funny on YouTube. It could be buying yourself one beautiful flower. You could be eating a really good piece of chocolate. Think about what your needs are. You know we run through life just trying to get through everything, but we really don't stop and think about who can meet which of the needs in your life. And you've got to think about which of your needs can you meet.

I don't let my patients go to baby showers, I tell them that they're under doctor's orders not to go to baby showers or birthday parties or gender reveals. And you know, I have some patients who are fine going. Most of my patients are not fine going. And so if you're invited to an in-person baby-oriented event, it's just a tragedy you are going to develop a stomach bug that morning. Or you're going to be exposed to COVID or something. Just don't go. Send a nice gift and don't go.

Think about telling people what you're going through. You know, as my colleague, I think it was Dr. Kaplan who said, you know, infertility is really, really common. Maybe I think it was Dr. Woodward. Anyway, if one in eight or one in seven or one in six people have infertility, you know, if you know a certain number of people, in all likelihood, someone's been through infertility. And talking to someone who's been through it can really help you from their experiential perspective.

But don't talk to people and you know who they are, who tend to offer unsolicited advice or just can't offer support if they're super competitive. And you do know who they are so just be careful who you talk to. Talk to people who are going to help you and avoid the people that you know won't.

So I'm a big believer in snappy comeback lines I want you to memorize. Basically, you know the kind of things people say to you that bug you. You know, just relax and you'll get pregnant or just adopt or whatever. So I want you to think of the things that people say that really bug you and then memorize snappy comeback lines. And these can be polite. They can be educational or they can be zinging. And I personally really liked the zingy. I've added a ton of zings to the app. They got removed because they were too offensive. So I obviously can't say anything offensive on this webinar. So I'll behave myself. But so if your intrusive aunt or snotty cousin or competitive co-worker said, so you know, when are you guys gonna think of someone else for a change and have a baby? People do say that. A polite response will be, oh you'll be one of the first to know. Or you can say, you know, some things just don't come as easily to some of us, but when we have good news to share, we will. Or if you figured that the question came not from a sense of being nice, just zing them - you know, we'll just see how the dog turns out. So again same thing, so whose fault is it? And yes, people do say this to my patients. And you can have a polite response, as you can see, an educational response, and a zinger. I mean, I know zingers are controversial, but I think, you know, when people say things to you, are they coming from a sense of love, or are they not? And if they're not coming from a sense of love, I don't see anything wrong with sometimes just zinging people right back.

So in general, to summarize, you know we know that infertility is associated with very high levels of stress. Many years ago, showing that women with infertility had the same amount of distress as women with cancer and heart disease, and we actually published a paper last year, same with COVID. There is so much that you can do to increase your sense of control and lower your distress. It's up to you. And just try out some of these suggestions. Whether or not you try relaxation or, you know, do challenging automatic negative thoughts, or you know, don't go to baby showers, or memorize some snappy comeback lines. However, the research has shown that women and men who use these strategies can really feel less anxious and depressed and can get back to their pre-infertility selves. This might increase the chance of conception, but it definitely makes it easier if you're less anxious and depressed to pursue the treatment that you need to achieve the conception of your healthy baby. Thank you.

Lake: Okay, well, thank you. Thank you so much to my colleagues, Dr. Woodward, Dr. Kaplan, and Dr. Domar. I've known you all for years in our professional work, through ASRM, and the Mental Health Professional Group. It's a privilege and I really appreciate being able to hear how you guys approach talking to someone when they come into your office with some of these issues and some of these concerns. It's obviously helpful for me to hear that. Hopefully, the information that you guys have presented will help you going through your fertility journey and your fertility treatment. To know a little bit more about some of the common experiences that people have with fertility. To know that you're not alone. You're not going crazy. You're not experiencing something that is abnormal. It helps you to know how to navigate your journey with your partner because, obviously, that is a critical piece of our lives. Our relationship is obviously crucial to that and to starting a family. And hopefully you can give some of the strategies that Dr. Domar suggested a try. As she said, everybody is very individual, so some things will work for you, and some won't. And sometimes it takes a little bit of practice to find those that will be the most helpful for you.

I am going to open up the question box and see what we have.

So the first one is kind of interesting. The question is do you think that every fertility center should have a clinical psychologist available to counsel patients? So I know that that's obviously a general topic, Does anybody care to take that one on?

Woodward: Of course, we have a very particular perspective to answer that question but one of the reasons why I think my answer is yes is because you know being able to serve embedded at our fertility center here at Duke, one of the things I see is not only is it such an advantage for the patients to to have their emotional needs so readily addressed, so easily addressed, but it also makes a big difference for the team. I think that the nurses and the doctors are frequently so grateful and relieved that instead of trying to get this patient to stop crying and get through this visit in a way that doesn't feel right to them, they say hey, I'm gonna go get Dr. Woodward. Let me get you the support that you really deserve. Because our providers, all reproductive medicine providers, really want to care for the patient as a whole, and knowing that there's a specialist who can offer very targeted strategies and support, I think it's good for the team. And I think it's so much better for the patient.

Domar: Absolutely. So, a couple of things: one is, you know, I totally agree with what Dr. Woodward said, but I would qualify; I don't think it needs to be a licensed clinical psychologist. Because I think we have to acknowledge psychiatrists, social workers, LMHCs, I mean if you look at the roll call of the Mentals, as we call ourselves, they're people from all kinds of different backgrounds and I don't think someone has to have a PhD in psychology to be able to adequately counsel people. I have a PhD but that's beside the point. And you know I think Dr. Woodward and I are two of the only embedded mental health professionals in the country. It used to be that almost every clinic had somebody on site and that's slowly disappearing. And I feel like the last thing I would want is for us to become extinct because I totally agree it's extraordinarily beneficial not just for the patients but for the team.

You know, I was at a meeting yesterday, we're discussing a patient, and you know it's a patient of mine, so I could add some of the perspective. And so you know her physician, her team, in hearing some of the background information as opposed to thinking, oh my god, this woman is really difficult and very challenging, and let's discharge her from the practice. When I would give them some perspective of where she was coming from, they began to understand sort of what made her tick.

And so anyway, just before the pandemic, you know, we were physically there. Someone came in for a prenatal ultrasound and there was no heartbeat. They could see one of the Mentals, one of the mental health professionals within an hour. And so I think there's a huge advantage to having someone embedded in the practice.

Lake: Yeah and I think for all of us, we recognize and realize that this is a multi-disciplinary field. Whether people look at it that way or not, it is. Because this does affect so many different aspects of our lives and so even if there isn't one associated with your fertility center, seeing someone who has some experience in counseling people who have had fertility issues or reproductive medicine, reproductive psychology therapy, can be helpful.

Okay, the next question really has to do with whether there are any good resources for support groups, whether they're in person or online. Someone has been looking for support groups but has not been able to find any. Do any of you have some ideas about support groups?

Kaplan: So the first thing that I would say is that RESOLVE the National Infertility Organization is a wonderful resource. ASRM and RESOLVE have recently partnered with each other and I think that's to everybody's benefit. Some RESOLVE support groups are peer-led. Some are professional-led. Some focus on specific populations like single parents, older parents, or people who are experiencing secondary infertility, which is to say it was easier the first time than it is now. So that's the first stop that I would go to is the RESOLVE website.

Lake: Someone has asked how to cope with really low motivation. That is the struggle. And I'm gonna just throw out there that it may indeed be a symptom or an experience that is well I know it's associated with depression. So that certainly may be part of what's going on.

Woodward: I find a lot that with patients who are experiencing low motivation, they have this idea that they need to feel much more energetic in order to to begin the process of doing something. And I think what we know is it really works in the opposite direction. It's that beginning to do something begins to increase energy and motivation. And so it's often about outlining what is the most palatable first step that you can take to move yourself from being in bed or being on the couch to moving out into the world. And really not not pushing too hard, not making it too complicated and just thinking about the first best step. And then also I often think that involving others around you whether that's a partner or friend to say, hey like I'm having a really hard time getting moving, like can you come partner with me, can you come get me, can we go do something together?

Lake: i would add that it's important for people to not judge themselves for having difficulty getting started or or for feeling like they can't get started. I think we find that that people often add to the negative things that they already feel about themselves by judging themselves because they can't do something or they should be able to do something. And we know that that just adds tenfold. And the fact is you're doing the best you can. And you take it one step at a time and one day at a time.

Domar: I think I would also add that if you don't feel motivated to go for treatment, that's okay. And yeah my first thought when I heard it was you know that feelings like that can go hand in hand with depression. And I think you probably need to get assessed by a primary care physician or a mental health professional but not everybody who is infertile wants to go undergo infertility treatment. And if you don't want to undergo infertility treatment, that's okay. I mean, I even had a patient who, you know, was really struggling with all this, and she went so far as to undergo an IVF-PGT cycle. And has, you know, normal blastocysts in the freezer and just realized that she didn't really want to be pregnant right now. And was feeling really guilty about that. And I reassured her like, you know the clock has stopped ticking. You know they're in the freezer. There's no one pressuring you to be pregnant right now. It's really okay and how you're feeling right now, it is the way you need to feel.

Kaplan: Yeah and if I may add one last thing to that. There are seasons to motivation. And we can hold more than one value at the same time. So I may really value the idea of having a family and I may also really value the idea of professional development or nurturing my creativity or getting into contact with my spirituality. And we often will talk about values in conflict, which is to say you can care very deeply about more than one thing. So it may be that what you're motivated to do in this moment doesn't mean you don't care about those other things, it means that right now this is where you want to put your energy.

Lake: Alright, we have someone who has asked about advice in talking to your partner and what to do when you've talked to them about how you need them to support you, but they're not really listening perhaps, and you know at the same time, learning to support them.

Kaplan: I will take this one but I also want to say I want to fling this one wide open because I think there are lots of reasons for that. There are a lot of things that get in the way of partners being able to hear each other and provide each other with what they need. And it ranges really from, I am so distressed that I need to sell soothe before I can hear you, which is really common, to I am hearing something in a way that's different from how you're intending it. My own couple's therapy supervisor used to say we all hear things through a lens. I am speaking through one lens. It gets filtered through another one. So it's like playing a giant game of telephone. Even if you're sitting in the same room there are a lot of things that can get in the way of people hearing how you need to be supported.

So I'm going to go back to communication 101 here. Lots of "I" statements. This is my experience. This is where I am in this present moment. Lots of checking in with your partner to see if they're hearing you and feeling heard. Lots of understanding when it might be the right moment and when it might not be the right moment to talk about these things. I might be much better able to have a really involved discussion that involves going through a lot of data, not the minute before I'm about to fall asleep. This may be the only time that somebody else can finally get to this part of the day and say I need to talk to you right now. So I think it's a big question. There's a lot that goes into it but the first thing I would say is don't assume your partner can't hear you. Try to think about the things that might be getting in the way of them hearing you at this moment.

Domar: My favorite thing to say to patients when they complain about their partner, is it can't or is it won't. You know your partner's not doing this because he, she, or they won't, or is it because they simply can't? And I think that it really helps too to look at what kind of parenting did your partner have, what kind of role models were their parents. I was seeing a couple a few years ago, and she really wanted something from her husband, and you know, he's looking like a deer caught in the headlights. And I said to him have you ever seen your Dad do that for your Mom? He said, Never, like I have no idea what she's talking about. He just didn't know what she wanted and she really had to explain that she thought of it because she saw her father do it for her mom. So I think we make these assumptions that our partner knows what we want and need and is deliberately choosing to not do it versus maybe they just can't.

Woodward: Another dynamic that I see so commonly in couples is that when one partner is expressing a lot of distress and upset, the other partner flips into the cheerleader role. They become really hopeful. It's really early in treatment. There are so many more things we can do. And their goal is to keep this ship from sinking but what happens is it often leaves that first person feeling like you don't get it. You're not as upset about it as I am. You don't want it as much as I do. And they end up feeling really alone. So sometimes, helping the other partner to just join and be like, yeah, this is scaring me too. Like I didn't know we were gonna have to have all of this intervention. I didn't know it was going to take so long. And this is really hard on me also. Instead of sinking the ship it actually brings the couple together. But lots of you know very unique pathways and you know lots of really important discussions to have.

Lake: So I've got a couple of questions to sort of piggyback a little bit on each other. One I think is sometimes the difficulty that people have with their families and friends particularly families who just don't understand or who are saying, why aren't you coming to the family Mother's Day? When are you gonna get over this? And just kind of keep sort of repeating and that gets to be really difficult and painful. So, do you have any ideas or suggestions about how to talk to your family about some of those specific questions and issues?

Domar: You knew I was gonna say zingers. I think family and friends are entitled to understand if you are not joining them for holidays, birthdays, and other celebrations. You know most of my patients couldn't join their family for Mother's Day for example, if it was all going to be about their sibling's babies and things like that. But you know I think it really depends on the family. I mean, there are some families where you can say, look, this is just too painful for me. I need to be self-protective. I'll see you in a year or two when I can celebrate Mother's Day. And there's some families that were like, oh we didn't really understand. We love you, and of course, we'll see you in a couple of years. And there are other families who get angry and don't understand where the couple's coming from. I think sometimes, if someone hasn't been through infertility, maybe they truly don't understand. As a doctor, you understand how incredibly pervasive it is in terms of how it just metastasizes into all areas of your life. But you gotta take care of yourself. You gotta be self-protective of yourself and your partner if you have one. And don't put yourself in situations that you suspect are gonna cause you overwhelming amounts of pain.

Lake: I think I would also say that for folks who don't understand, you don't know when you are going to get over this. There's no timeline for grief. There is absolutely no timeline for grief. So you are experiencing your grief and your feelings in the time and the way that you are experiencing them. And that is okay. And you don't need to change that for anyone else. As Dr. Domar said, you may need to explain it, and I think the best you can do is to maybe just explain it and hopefully ask your relatives to try to be understanding. And to know that this just is something that you're working through. I think in terms of asking them to educate themselves. I think there are some resources on ReproductiveFacts.org from ASRM that can help you find some fact sheets or some information to give your family. But again, like Dr. Domer said, a lot of times it's very specific to each family and to the dynamics within that family.

Kaplan: I would add two things to that. One is that it's also somewhat culture-specific. There are certain cultures where family and extended family just are the units in which we function. And so I think it can be really painful if it's the big extended family. If you ask me how many people are in my family I will say 23. I'm an only child but that's the culture in which I was raised. So I think some recognition that this issue really does impact people very differently depending on what their family unit is. I would also add that this is a really good opportunity for both ends of thinking. I think that there is a lot of conflict that emerges when people say either you care about my feelings or you don't. This is also an opportunity for people to say to their parents and their siblings, I care about how you feel, and I need to protect myself. I'm happy for you and I'm struggling. So that it doesn't become a you versus them. It's two realities that are true at the same time.

Woodward: I think often some of those comments can be motivated by the family's difficulty in watching the patients suffer. It's like I see that you're in pain. Like are you going to finish so it doesn't hurt so much anymore? So sometimes it's about being able to provide that information to them. I've read a number of articles and fertility blogs that patients have said I can't say this in my own words, but here, read this. This is what it's like to be living this experience. That's been often helpful in bringing family into a place of understanding. The critical importance of connecting with other people who do get it, who completely understand this pain, and who know that it doesn't just resolve quickly. So whether that's through a formal support group or something online or reading something. Being able to connect with other people who do understand even if the family doesn't, I think, is really critical.

Lake: Two more questions. One is going to be advice to talk to a friend who's pregnant and let her know that you want to support her but also that you can't take part in some of the planning for the shower and things like that. So let's start with that. Maybe this just goes back to what Dr. Domar was saying about you know really kind of deciding what you can participate in and what you can't and really just being able to express that you know right now this is just isn't something that you can do and feel like you can fully participate in in a way that is going to be good for you or good for your friend. And you can be supportive of her and also feel like you can't participate. The two things exist together and that's okay. And hopefully, your friend will understand. You'll participate when you can.

Domar: I really like what Dr. Kaplan said, I think we also remember that infertility is a temporary crisis. You're not going to be trying to get pregnant and going through treatment for the rest of your life. There may well be a time in the future when these things will not bother you. So it's not like you're never gonna celebrate your friend's baby. It's that you just can't do it right now,

Lake: So I think this is going to be a really important one. Strategies to help get through the waiting periods. So waiting for your embryos to fertilize and to grow, waiting for the pregnancy test, waiting for the PGT tests, waiting for the next cycle.

Domar: That's the worst part of it all. Now, doing PGT has, in effect, doubled the waiting period. So you're not just waiting between transfer and pregnancy, you're also waiting between retrieval, fertilization, blastocyst, and then seeing how many made it who are normal. I tell patients before they start a cycle to literally start keeping a coping list. What are all the things that you know that you can do to help you feel better. I was just talking to two patients today. We just started their coping lists. Between embryo transfer and pregnancy test is a very very long 10 days. You can't just sit at home and like stare at your belly. You can't go to the bathroom every five seconds. You can't keep on doing home pregnancy tests. You know presumably you still have to go to work. That's the time to practice every coping technique, every relaxation strategy, every distraction that you know you can use. Because the research has shown that's the toughest time of the whole thing.

Woodward: I often talk to patients about this experience of going into the future in their minds. We talk about the what-if tree. So right now is the trunk of the tree. They just start going up the tree. They're following all the branches and all the ways that this might happen and that might happen. So helping them to appreciate that this is the process their mind is going through and being able to notice when it gets started and then coming back to the trunk of the tree like where am I right now, what am I doing today, what is the thing I can offer myself that will give me some comfort, and that will keep me out of the wettest. So dropping anchor, I think, is a really important part of the process, going from future focus to present focus, just to get through these waiting times.

Domar: I try with all my patients before they start a cycle to always have a plan B so that it's not just that cycle. That if that cycle doesn't work they have something that feels okay to try next.

Lake: Dr. Domar this is a question on any information about the connection or correlation between stress and live birth rates.

Domar: That's a whole other webinar. I just wrote a really comprehensive opinion piece for Fertility Smarts. I think it's fertilitysmarts.com. And it really talks about some of the data on stress. We know infertility causes a lot of stress, but does stress cause infertility? I've spent my entire career researching it. I have an opinion, which is not shared by some of my colleagues. I think some of the best research that I think is really cutting-edge is because you can't just hand somebody a questionnaire to find out how stressed they are; people know what their prognosis is. So there's this really interesting research group, I think it's in Scandinavia. But it could be the Netherlands, and I'm sorry if I futzed that up. Where they're looking at hair cortisol levels because cortisol in your hair actually pretty much reflects your cortisol levels for the previous three to six months. Stress can be manifested as cortisol levels. As far as I know they've done two or three studies where they've looked at women who are scheduled to start an IVF cycle. They've cut off a really big thatch of hair at the beginning of their IVF cycle, and they've analyzed the cortisol in their hair, which should reflect the stress they've experienced over the previous few months. They have found a very, very strong correlation between hair cortisol level and pregnancy rate, so women with the highest cortisol level had the lowest pregnancy rates. I think if they continue to do that research, having physiological data I think is more reliable than simply asking someone how stressed or anxious they are right now. I mean, you also look at the intervention data, and a group I know from Scandinavia named Fredrickson, they've done a series of meta-analyses on, you know, 20 or 30 or 40 different intervention studies. They have concluded that psychological interventions are related to significant decreases in psychological symptoms and significant increases in pregnancy rates. That is actually what I personally believe.

Kaplan: So I'm just going to piggyback on that and say one thing. Actually this is something that I've heard Dr. Woodward say before as well, everybody in a fertility clinic is stressed. Everybody, right? So there are many people who experience stress and get pregnant. There are many people who find this process aversive and onerous and time consuming and upsetting and get pregnant. There's a phrase that I like to use from the literature called the "double punishment". The first one is that you have to go through all this to begin with and the second one is believing that if you don't meditate 20 times a week you're not going to get pregnant. So again I think we're in both and territory. That to normalize that. If you are, if you're on this webinar, you're probably stressed about this.

Lake: I've seen a several questions about you know how to how to talk to your spouse about you know when you're going to get started again with the next cycle, when you've been through a lot already. I think there's also another question about the fact that many of our clinics are really focused on the female partner and not so much the male partner whether it's male factor or female factor or unexplained. Unfortunately that is the fact because it's the woman who has to go through all the procedures to actually get pregnant. So we often forget the husband. So on how to kind of rebalance that treatment process with the husband. Also I think just being on the being on the fence when your husband maybe is in a different place than you are.

Kaplan: I think that what I want to remind you of, and what I want to bring us back to is that very few couples have planned for this. Very few couples know at the beginning of their relationship or at the beginning of their fertility treatment exactly how far they want to go. So realistically I think this speaks to Dr. Domar's point about having a plan B. I think it speaks to a question of timing. The day that you get negative pregnancy test results is probably not the day when you know exactly what you're going to do next. But it is the day when you're going to look at each other and one of you is going to say let's stop, and the other one is going to say let's keep going. Because you're both trying to cope in that moment. There's an expression that actually comes from the pregnancy boss world which is that two people who go blind on the same day can't teach each other braille. I think that this is very much the experience of couples getting negative pregnancy test results is okay what do we do now? On your mark, get set, go. So I guess the first thing I would encourage you to do is slow it down and understand that those are the hardest times to make decisions and they're the times you're going to most want to.

Lake: And if you do, it's okay to be in different positions. It's okay for one of you to say I need a little bit of time and I don't know what our next step should be. If you have a counselor, perhaps that would be a time when your spouse can join you for a session or just to talk about how to talk about this in a way that that feels more helpful to both of you.

There are several other questions that are still out here and I'll have to ask sarah our organizer about how we can address those. My guess is that likely we'll have to answer them either through email or privately. So at this point I will call this to a close. I really appreciate all of you participating in this panel. And for all of you for who asked us really good questions. I wish you all the best of luck on your journeys and have a good have a good rest of your evening.

Ramaiah: Thank you Dr. Lake. So we are over our time and I see many questions trickling in. Please know that your questions will be addressed. Thank you Dr. Lake for making every effort to address as many questions as possible and moderating such a fantastic session. Thank you to our panelists for bringing such an important topic up for discussion and for staying beyond your planned time to take the questions. And to the attendees, thank you for joining us. You will receive a survey by email after this session and your feedback helps us give you the most relevant content. Your input is appreciated. This session was recorded and will be available on our website in the near future. Please watch your email for notifications about future webinars. For any further questions or comments please don't hesitate to contact us at webinars@asrm.org. This concludes the webinar.